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Good Faith Estimate Disclaimer

No Surprises Act & Good Faith Estimates Disclaimer

Understanding Your Rights:

Under the No Surprises Act, you have protections against surprise medical bills and the right to receive a Good Faith Estimate for the expected cost of non-emergency healthcare services.

Surprise Billing Protections:

  • Emergency Services: If you receive emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing. You should not be charged more than your plan’s in-network cost-sharing amount.

  • Non-Emergency Services: If you are treated by an out-of-network provider at an in-network facility, the provider cannot balance bill you unless you give written consent and agree to pay more.

Good Faith Estimates:

You have the right to receive a Good Faith Estimate explaining how much your medical care will cost:

  • For Uninsured or Self-Pay Patients: If you do not have insurance or choose not to use your insurance, you have the right to receive an estimate of the expected charges for your medical care.

  • When to Expect the Estimate: You should receive a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your healthcare provider for an estimate before you schedule an item or service.

  • Binding Nature of Estimate: The Good Faith Estimate is not a bill. The actual charges may differ if additional services are needed or if complications arise.

Dispute Resolution:

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. You may contact the Department of Health and Human Services (HHS) to start the dispute resolution process.

Contact Information for Disputes:

Filing a Complaint:

If you believe you have been wrongly billed or would like to report any other concerns regarding surprise billing, you may contact:

Arizona Department of Insurance and Financial Institutions

  • Address: 100 North 15th Avenue, Suite 261, Phoenix, AZ 85007

  • Phone: (602) 364-3100

  • Toll-Free: (800) 325-2548

  • Website: https://difi.az.gov

Baseline Psychiatry Contact Information:

Your privacy will be protected, and there will be no retaliation for filing a complaint.

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